This three-year project seeks to improve care quality and safety in an ambulatory care setting through clinical decision support for evidence-based pharmacotherapy delivered as point-of-care reports to clinicbased practitioners and as population health-based alerts to care managers. This project will build upon a regional Health Information Exchange (HIE) network created to connect providers serving 37,000 Medicaid beneficiaries across traditional institutional boundaries from both rural and urban settings in a 5 county region in the Northern Piedmont of North Carolina. This network includes 16 private practices, 3 federally qualified health centers, 5 rural health clinics, 3 urgent care facilities, 10 government agencies, 5 hospitals and 2 cross-disciplinary care management teams. Rules for evidence-based pharmacotherapy for priority areas identified by the Institute of Medicine (IOM) will be encoded in a standards-based decision support tool that has been in use within the HIE network for three years to promote population health management. These rules will be designed to function using routinely available claims and scheduling data in order to make the proposed approach more generalized, portable and scalable. This approach will support both traditional clinic-based models of care, and new care models including population health management and the use of cross-disciplinary teams. Under Aim 1, the existing HIE network will be enhanced to deliver reports comprised of patient-specific medication adherence data (% days covered by each medication) and evidence-based suggestions for medication management to clinicians at the point of care prior to a scheduled patient appointment using bidirectional facsimile technology, and to deliver notifications about patient-specific medication adherence asynchronously to care managers via electronic mail. Under Aim 2, the impact of the proposed approach will be evaluated in a randomized controlled trial involving 4,200 patients, 248 primary care clinicians and 22 care management workers. Patients with IOM priority conditions will be randomly assigned by family unit to one of three groups: 1) patients for whom medication management suggestions are sent both to their clinic-based caregivers and their care managers;2) patients for whom suggestions are sent only to their clinic-based caregivers;and 3) patients for whom no suggestions are sent. The primary outcome measure will be the overall rate of adherence to evidence-based pharmacotherapy for each study group. Under Aim 3, the economic attractiveness of the proposed approach will be determined. Under Aim 4, the technology and results of this study will be disseminated through publications and presentations. The primary study hypothesis is that adherence to evidence-based pharmacotherapy will be highest among patients who receive medication management information sent both to their clinic-based practitioners and to their care managers. The expected effect on safety/quality from this project will be improved adherence to evidence-based pharmacotherapy guidelines.